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Clinical Medicine (London, England) Mar 2022Diplopia or double vision is the separation of images vertically, horizontally or obliquely and can be monocular or binocular in origin. Binocular diplopia is most...
Diplopia or double vision is the separation of images vertically, horizontally or obliquely and can be monocular or binocular in origin. Binocular diplopia is most commonly caused by ocular misalignment or strabismus that can be detected using simple clinical tests. All patients with diplopia of acute onset should be investigated urgently and those with a headache or pupillary involvement need to be referred for same-day urgent imaging. Diplopia secondary to microvascular causes on the other hand often spontaneously resolves within six months.
Topics: Diplopia; Humans
PubMed: 35304368
DOI: 10.7861/clinmed.2022-0045 -
Continuum (Minneapolis, Minn.) Oct 2019"Double vision" is a commonly encountered concern in neurologic practice; the experience of diplopia is always sudden and is frequently a cause of great apprehension and... (Review)
Review
PURPOSE OF REVIEW
"Double vision" is a commonly encountered concern in neurologic practice; the experience of diplopia is always sudden and is frequently a cause of great apprehension and potential disability for patients. Moreover, while some causes of diplopia are benign, others require immediate recognition, a focused diagnostic evaluation, and appropriate treatment to prevent vision- and life-threatening outcomes. A logical, easy-to-follow approach to the clinical evaluation of patients with diplopia is helpful in ensuring accurate localization, a comprehensive differential diagnosis, and optimal patient care. This article provides a foundation for formulating an approach to the patient with diplopia and includes practical examples of developing the differential diagnosis, effectively using confirmatory examination techniques, determining an appropriate diagnostic strategy, and (where applicable) providing effective treatment.
RECENT FINDINGS
Recent population-based analyses have determined that diplopia is a common presentation in both ambulatory and emergency department settings, with 850,000 such visits occurring annually. For patients presenting to an outpatient facility, diagnoses are rarely serious. However, potentially life-threatening causes (predominantly stroke or transient ischemic attack) can be encountered. In patients presenting with diplopia related to isolated cranial nerve palsy, immediate neuroimaging can often be avoided if an appropriate history and examination are used to exclude worrisome etiologies.
SUMMARY
Binocular diplopia is most often due to a neurologic cause. The onset of true "double vision" is debilitating for most patients and commonly prompts immediate access to health care services as a consequence of functional impairment and concern for worrisome underlying causes. Although patients may seek initial evaluation through the emergency department or from their primary care/ophthalmic provider, elimination of an ocular cause will not infrequently result in the patient being referred for neurologic consultation. A logical, localization-driven, and evidence-based approach is the most effective way to arrive at the correct diagnosis and provide the best outcome for the patient.
Topics: Adult; Diplopia; Humans; Male; Middle Aged
PubMed: 31584541
DOI: 10.1212/CON.0000000000000786 -
The American Orthoptic Journal 2015Torsional diplopia can result in failure of fusion in an individual without a measureable strabismus. When presented with a patient with complaints of binocular... (Review)
Review
BACKGROUND AND PURPOSE
Torsional diplopia can result in failure of fusion in an individual without a measureable strabismus. When presented with a patient with complaints of binocular diplopia, physicians and orthoptists should consider cyclovertical muscle dysfunction when the source of the complaint is not readily apparent.
METHODS
A thorough review of the literature combined with the author's own personal experience in treating adult patients with strabismus was used to evaluate the different potential causes of torsional diplopia. Predisposing factors, diagnostic techniques, and strabismus diagnoses are considered.
RESULTS
The most common cause of torsional diplopia is a superior oblique palsy. Other more common causes include thyroid-related orbitopathy and skew deviations.
CONCLUSIONS
Torsional diplopia is a common cause of undiagnosed strabismus in the adult patient population. Proper consideration of the most common causes should be made.
Topics: Diplopia; Eye Movements; Humans; Oculomotor Muscles; Trochlear Nerve Diseases
PubMed: 26564921
DOI: 10.3368/aoj.65.1.21 -
Romanian Journal of Ophthalmology 2017Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical... (Review)
Review
Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical examination must detail the type of diplopia (monocular/ binocular), onset, and progression, associated and relieving factors. In case of monocular diplopia, refraction and biomicroscopic examination of the ocular media are mandatory. The cause of ocular misalignment for binocular diplopia must be determined and life-threatening conditions (such as posterior communicating artery aneurysm) must imply an immediate treatment. Management and treatment is always according to the specific cause of diplopia.
Topics: Diplopia; Humans; Ophthalmologic Surgical Procedures; Ophthalmology; Vision Tests; Vision, Binocular
PubMed: 29450393
DOI: 10.22336/rjo.2017.31 -
Journal of Cataract and Refractive... Sep 2018
Topics: Diplopia; Exotropia; Humans; Keratomileusis, Laser In Situ; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Reoperation; Vision, Binocular
PubMed: 30165945
DOI: 10.1016/j.jcrs.2018.07.039 -
Journal of Neuro-ophthalmology : the... Sep 2016We describe 2 unique cases of visual symptoms occurring during mastication in patients with lateral orbital wall defects. A 57-year-old man reported intermittent double...
We describe 2 unique cases of visual symptoms occurring during mastication in patients with lateral orbital wall defects. A 57-year-old man reported intermittent double vision and oscillopsia after a right fronto-temporal-orbito-zygomatic craniotomy with osteotomy of the lesser wing of the sphenoid for a complex invasive pituitary adenoma. Proptosis of the right globe was present only during mastication. Computed tomography (CT) revealed a bony defect in the right lateral orbital wall. A 48-year-old man presented with transient diplopia and scotoma in the right eye elicited by chewing. CT and magnetic resonance imaging demonstrated a bilobed lesion connecting the temporal fossa to the orbit through a defect in the right lateral orbital wall. The regional neuroanatomy and pathophysiology as pertaining to these cases are discussed.
Topics: Craniotomy; Diplopia; Exophthalmos; Humans; Magnetic Resonance Imaging; Male; Mastication; Middle Aged; Orbit; Postoperative Complications; Sphenoid Bone; Tomography, X-Ray Computed
PubMed: 26919071
DOI: 10.1097/WNO.0000000000000354 -
Seminars in Neurology Aug 2016Diagnosing the underlying etiology of diplopia requires a structured approach. Double vision can arise from ocular, mechanical, or neurologic causes. A careful history... (Review)
Review
Diagnosing the underlying etiology of diplopia requires a structured approach. Double vision can arise from ocular, mechanical, or neurologic causes. A careful history can greatly improve a targeted examination. The approach to initial diagnosis and examination in cases of diplopia has been previously described. Here the authors expand upon those recommendations, and add new techniques recently described in the literature, which may influence the approach to the diplopia patient. A description of the approach to the examination of torsion is discussed. The "three-step test" in the diagnosis of vertical strabismus is discussed, and recent advances in diagnosing skew deviation with the upright-supine test are described. Mechanical strabismus due to changes in orbital anatomy is also reviewed. This review should help the reader refine the differential diagnosis of the patient with diplopia.
Topics: Diagnosis, Differential; Diplopia; Humans; Ocular Motility Disorders; Strabismus
PubMed: 27643904
DOI: 10.1055/s-0036-1585428 -
Survey of Ophthalmology 2022A 23-year-old man presented with new onset horizontal diplopia 5 months after a left orbital floor fracture. Examination revealed bilateral abduction deficits and disc...
A 23-year-old man presented with new onset horizontal diplopia 5 months after a left orbital floor fracture. Examination revealed bilateral abduction deficits and disc swelling. Urgent MRI and MRI showed no significant abnormalities in the CNS. Lumbar puncture revealed a minimally elevated opening pressure and significant leukocytosis. Additional CSF testing revealed probable Lyme meningitis. The patient responded to a course of oral doxycycline, with rapid resolution of his diplopia, abduction deficits, and disc edema.
Topics: Adult; Diplopia; Doxycycline; Humans; Male; Spinal Puncture; Young Adult
PubMed: 35718026
DOI: 10.1016/j.survophthal.2022.06.001 -
The American Orthoptic Journal 2015Maculopathies affect point-to-point foveal correspondence causing diplopia. The effect that the maculopathies have on the interaction of central sensory fusion and... (Review)
Review
Maculopathies affect point-to-point foveal correspondence causing diplopia. The effect that the maculopathies have on the interaction of central sensory fusion and peripheral fusion are different than the usual understanding of treatment for diplopia. This paper reviews the pathophysiology of macular diplopia, describes the binocular pathology causing the diplopia, discusses the clinical evaluation, and reviews the present treatments including some newer treatment techniques.
Topics: Diplopia; Eye Movements; Humans; Macula Lutea; Oculomotor Muscles; Retinal Diseases; Tomography, Optical Coherence; Vision, Binocular; Visual Acuity
PubMed: 26564922
DOI: 10.3368/aoj.65.1.26 -
Journal of the Neurological Sciences Oct 2020This article presents an overview of the most important points a neurologist must remember when dealing with a patient complaining of diplopia. Patients with monocular... (Review)
Review
This article presents an overview of the most important points a neurologist must remember when dealing with a patient complaining of diplopia. Patients with monocular diplopia and those with full ocular motility and comitant misalignment should be referred to an ophthalmologist and do not require further testing. Patients with recent onset of binocular diplopia who have associated "brainstem" symptoms should have an urgent brain MRI. All patients with 3rd cranial nerve palsy require urgent brain CTA to rule out compressive aneurysmal lesion. Management of patients over 50 years of age with microvascular risk factors with new onset of 6th nerve palsy is controversial: some image these patients at presentation while others choose a short period of observation as most of these patients would have a microvascular etiology for the 6th nerve palsy which should improve spontaneous in 2-3 months. All others with 6th nerve palsy require brain MRI with contrast. Patients with 4th palsy with hyperdeviation that worsens in downgaze should have an MRI with contrast and all others referred to an ophthalmologist. If there is more than one cranial nerve palsy, urgent neuroimaging should be performed with attention to cavernous sinus and superior orbital fissure. Ocular myasthenia should be suspected in patients with eye misalignment that does not fit a pattern for any cranial nerve palsy. Orbital pathology (most commonly thyroid eye disease) can result in restriction of ocular motility and has specific clinical signs associated with it.
Topics: Abducens Nerve Diseases; Diplopia; Humans; Infant; Magnetic Resonance Imaging; Oculomotor Nerve Diseases; Strabismus
PubMed: 32777577
DOI: 10.1016/j.jns.2020.117055